Multiple Choice
Identify the choice that best completes the statement or answers the question.
|
|
1.
|
A 78-year-old patient is being seen in the emergency department. The nurse observes his gait and balance appear to be slightly unsteady. What assessment should the nurse perform next?
|
a)
|
Perform the Get Up and Go Test. |
|
b)
|
Ask the patient if he has fallen in the past year. |
|
c)
|
Refer the patient for a comprehensive fall evaluation. |
|
d)
|
Administer the Timed Up and Go Test. |
|
|
2.
|
A patient has received a radiation implant. The patient is weak and needs help even to turn in bed. Which action should the nurse take when caring for this patient?
|
a)
|
Avoid giving the patient a complete bed bath. |
|
b)
|
Limit the amount of time spent with the patient. |
|
c)
|
Allow extra time for the patient to express feelings. |
|
d)
|
Do not allow anyone to visit the patient. |
|
|
3.
|
A patient is brought to the emergency department after inhaling mercury. The nurse should be alert for which acute adverse effects associated with mercury inhalation?
|
a)
|
Chest pain, pneumonitis, and inflammation of the mouth |
|
b)
|
Intestinal obstruction and numbness of the hands |
|
c)
|
Hypotension, oliguria, and tingling of the feet |
|
d)
|
Tachycardia, hematuria, and diaphoresis |
|
|
4.
|
Which aspect of restraint use can the nurse delegate to the nursing assistive personnel?
|
a)
|
Assessing the patient’s status |
|
b)
|
Determining the need for restraint |
|
c)
|
Evaluating the patient’s response to restraints |
|
d)
|
Applying and removing the restraints |
|
|
5.
|
The Joint Commission’s national Speak Up campaign encourages patients to become active and informed participants on the healthcare team. The goal is to:
|
a)
|
prevent healthcare errors. |
|
b)
|
help control the cost of healthcare. |
|
c)
|
reduce the number of automobile accidents. |
|
d)
|
provide a forum for people with no health insurance. |
|
|
6.
|
The patient takes anticoagulants. Which instruction is most important for the nurse to include on the patient’s care plan? “Teach the patient to:
|
a)
|
use an electric razor for shaving.” |
|
b)
|
apply skin moisturizer.” |
|
c)
|
use less soap when bathing.” |
|
d)
|
floss teeth daily.” |
|
|
7.
|
The nurse is caring for a patient admitted with a closed head injury. Which action by the nurse is appropriate when providing hygiene for this patient?
|
a)
|
Avoid bathing the patient. |
|
b)
|
Use cool water for bathing. |
|
c)
|
Provide care in small intervals. |
|
d)
|
Rub briskly when towel drying. |
|
|
8.
|
For which patient can the nurse safely delegate morning care to the nursing assistive personnel (NAP)? Assume an experienced NAP, and base your decision on patient condition. Assume there are no complications other than the conditions stated.
|
a)
|
32-year-old admitted with a closed head injury |
|
b)
|
76-year-old admitted with septic shock |
|
c)
|
62-year-old who underwent surgical repair of a bowel obstruction 2 days ago |
|
d)
|
23-year-old admitted with an exacerbation of asthma with dyspnea on exertion |
|
|
9.
|
For which patient is it most important to provide frequent perineal care? The patient:
|
a)
|
with active lower gastrointestinal bleeding. |
|
b)
|
after an episode of diabetic ketoacidosis. |
|
c)
|
who has a circumcised penis. |
|
d)
|
with a history of acute asthma. |
|
|
10.
|
A patient with dementia becomes belligerent when the nurse attempts to give him a tub bath. How should the nurse proceed?
|
a)
|
Call for assistance to help the patient into the bathtub. |
|
b)
|
Wait for the patient to calm down, and then give him a towel bath. |
|
c)
|
Allow the patient to go without bathing for a day or two. |
|
d)
|
Ask another staff member to attempt the tub bath. |
|
|
11.
|
The nurse is teaching nursing assistive personnel (NAP) how to give a complete bed bath. Which instruction should the nurse include?
|
a)
|
“Cleanse only those areas likely to cause odor.” |
|
b)
|
“Provide the patient with warm water for washing his perineum.” |
|
c)
|
“Wash the patient’s back, buttocks, and perineum first.” |
|
d)
|
“Bathe the patient from head-to-toe, cleanest areas first.” |
|
|
12.
|
Wearing poorly fitting shoes may result in which condition?
|
a)
|
Tinea pedis |
|
b)
|
Plantar wart |
|
c)
|
Excoriation |
|
d)
|
Ingrown toenail |
|
|
13.
|
Bath water should be prepared at which temperature to prevent chilling and excess drying of the skin?
|
a)
|
99°F (37.2°C) |
|
b)
|
102°F (38.9°C) |
|
c)
|
103°F (39.4°C) |
|
d)
|
105°F (40.6°C) |
|
|
14.
|
While assessing a patient, the nurse notes that the patient’s nails are excessively brittle. What does this finding suggest?
|
a)
|
Inadequate dietary intake |
|
b)
|
Normal aging process |
|
c)
|
Fungal infection |
|
d)
|
Excessive use of silver salts |
|
|
15.
|
Which item is best for providing mouth care for an unconscious patient?
|
a)
|
Foam swabs |
|
b)
|
Lemon-glycerin swabs |
|
c)
|
Hydrogen peroxide |
|
d)
|
Cotton-tipped applicator soaked in mouthwash |
|
|
16.
|
After receiving a course of chemotherapy, a patient begins losing hair. This adverse effect of chemotherapy should be documented as:
|
a)
|
pediculosis. |
|
b)
|
alopecia. |
|
c)
|
dandruff. |
|
d)
|
hirsutism. |
|
|
17.
|
Which of the following is a correct step in removing and cleaning a hearing aid?
|
a)
|
Clean only the external surfaces, not the canal portion. |
|
b)
|
Clean the top part of the canal portion of the device. |
|
c)
|
Insert a wax loop or toothpick into the hearing aid itself. |
|
d)
|
Remove the battery before taking the hearing aid from the ear. |
|
|
18.
|
A patient is prescribed fluoxetine 20 mg by mouth daily for treatment of depression. The nurse caring for the patient is unfamiliar with this drug. Which action should she take before administering the medication?
|
a)
|
Inform the prescriber that she is not comfortable administering the drug. |
|
b)
|
Ask a nursing colleague for relevant information about the drug. |
|
c)
|
Consult the drug formulary accessible to staff at the patient care unit. |
|
d)
|
Trust the prescriber writes the dose and administer the drug as intended. |
|
|
19.
|
A surgeon prescribes potassium chloride 20 mEq by mouth for a patient with a nasogastric (NG) tube for gastric drainage. How should the nurse proceed?
|
a)
|
Seek clarification from the surgeon about the medication order. |
|
b)
|
Clamp the NG tube while administering the dose by mouth. |
|
c)
|
Instill the medication through the NG tube. |
|
d)
|
Withhold the oral potassium chloride elixir. |
|
|
20.
|
A patient calls the nurse because he is having incision pain and wants a dose of analgesic medication. When the nurse checks the patient’s medication administration record, she notes that he is prescribed the opioid, hydromorphone (Dilaudid). Where should the nurse expect to retrieve this drug for administration?
|
a)
|
Cabinet in the patient’s room |
|
b)
|
Double-locked medication drawer |
|
c)
|
Stock supply cabinet |
|
d)
|
Portable medication cart |
|
|
21.
|
The time it takes for drug concentration to reach a therapeutic level in the blood is known as:
|
a)
|
Peak action |
|
b)
|
Duration of action |
|
c)
|
Onset of action |
|
d)
|
Half-life |
|
|
22.
|
Which factor in a patient’s medical history is most likely to prolong the half-life of certain drugs?
|
a)
|
Heart disease |
|
b)
|
Liver disease |
|
c)
|
Rheumatoid arthritis |
|
d)
|
Tobacco use |
|
|
23.
|
Teratogenic drugs should be avoided in which patient population?
|
a)
|
Pregnant women |
|
b)
|
Elderly |
|
c)
|
Children |
|
d)
|
Adolescents |
|
|
24.
|
While receiving an intravenous dose of an antibiotic, levofloxacin, a patient develops severe shortness of breath, wheezing, and severe hypotension. Which action should the nurse take first?
|
a)
|
Administer epinephrine IM. |
|
b)
|
Give bolus dose of intravenous fluids. |
|
c)
|
Stop the infusion of medication. |
|
d)
|
Prepare for endotracheal intubation. |
|
|
25.
|
Laboratory test results indicate that warfarin anticoagulant therapy is suddenly ineffective in a patient who has been taking the drug for an extended time. The nurse suspects an interaction with herbal medications. What type of interaction does she suspect?
|
a)
|
Antagonistic drug interaction |
|
b)
|
Synergistic drug interaction |
|
c)
|
Idiosyncratic reaction |
|
d)
|
Drug incompatibility |
|
|
26.
|
A patient with terminal cancer requires increasing doses of an opioid pain medication to obtain relief from pain. This patient is exhibiting signs of drug:
|
a)
|
Abuse. |
|
b)
|
Misuse. |
|
c)
|
Tolerance. |
|
d)
|
Dependence. |
|
|
27.
|
Which documentation entry related to PRN medication administration is complete?
|
a)
|
6/5/11 0900 morphine 4 mg IV given in right antecubetal fossa for pain rated 8 on a 1–10 scale, J. Williams RN |
|
b)
|
0600 famotidine 20 mg IV given in right hand, S. Abraham RN |
|
c)
|
9/2/11 0900 levothyroxine 50 mcg PO given |
|
d)
|
1/16/11 furosemide 40 mg PO given, J. Smith RN |
|
|
28.
|
How should the nurse dispose of a contaminated needle after administering an injection?
|
a)
|
Place the needle in a specially marked, puncture-proof container. |
|
b)
|
Recap the needle, and carefully place it in the trash can. |
|
c)
|
Recap the needle, and place it in a puncture-proof container. |
|
d)
|
Place the needle in a biohazard bag with other contaminated supplies. |
|
|
29.
|
The physician prescribes warfarin 5 mg orally at 1800 for a patient who underwent open reduction and internal fixation of his right hip. After administering the medication, the nurse realizes that she administered a 10 mg tablet instead of the prescribed 5 mg PO. Which of the following actions by the nurse is appropriate?
|
a)
|
No action is necessary because an extra 5 mg of warfarin is not harmful. |
|
b)
|
Call the prescriber and ask her to change the order to 10 mg. |
|
c)
|
Document on the chart that the drug was given and indicate the drug was given in error. |
|
d)
|
Complete an incident report according to the facility’s policy. |
|
|
30.
|
The nurse is teaching parents ways to give oral medication to their child. Which action would they implement to improve compliance?
|
a)
|
Crush time-release capsules to put in his favorite food. |
|
b)
|
Give medication quickly before he knows what is happening. |
|
c)
|
Allow the child to eat a frozen pop before receiving the medication. |
|
d)
|
Mask the flavor of medication in a toddler cup with orange juice. |
|
|
31.
|
A patient with a diabetic foot ulcer will need to perform dressing changes after discharge. When should the nurse schedule the teaching session(s)?
|
a)
|
Within 10 minutes after his next dose of oral pain medication |
|
b)
|
After the patient wakes up from a restful nap |
|
c)
|
Before the surgeon débrides the wound |
|
d)
|
Before the patient undergoes flow studies of his affected leg |
|
|
32.
|
Assume all of the following written instructions about digoxin provide correct information for patient care. Which one is best worded for patient understanding?
|
a)
|
Obtain your radial pulse every morning before taking your digoxin dose. |
|
b)
|
Return to your healthcare provider for monthly laboratory studies of your digoxin levels. |
|
c)
|
Call your doctor if you notice that objects look yellow or green. |
|
d)
|
Always take the same brand of medication because certain brands may not be interchangeable. |
|
|
33.
|
Which teaching strategy is typically most effective for presenting information to large groups?
|
a)
|
Distributing printed materials |
|
b)
|
Lecturing using audiovisual format |
|
c)
|
Human patient simulation |
|
d)
|
Using computer-assisted instruction (CAI) |
|
|
34.
|
A patient with attention deficit disorder is admitted to the hospital with type 1 diabetes. Which nursing diagnosis is commonly yet inappropriately used but should be avoided for this type of patient? Assume there are data to support all the diagnoses.
|
a)
|
Deficient Knowledge (disease process) |
|
b)
|
Impaired ability to learn related to fear and anxiety |
|
c)
|
Difficulty learning related to cognitive developmental level |
|
d)
|
Lack of motivation to learn related to feelings of powerlessness |
|
|
35.
|
During family therapy, to improve communication skills the nurse teaches family members to rehearse responses to situations involving interpersonal conflict. What is the primary drawback of using this teaching strategy?
|
a)
|
Some people might have difficulty with an interactive approach when there is conflict among participants. |
|
b)
|
Nurses might rehearse responses that are not effective for resolving interpersonal conflict. |
|
c)
|
Nurses don’t use the rehearsal technique because it’s an inefficient use of time for participants. |
|
d)
|
This type of interactive teaching strategy is not as effective as dispersing information verbally or in print. |
|
|
36.
|
Prior to discharge, a patient with diabetes needs to learn how to check a finger-stick blood sugar before taking insulin. Which action will best help the patient remember proper technique?
|
a)
|
Encouraging the patient to check the blood sugar each time the nurse gives insulin |
|
b)
|
Providing feedback after the patient takes his blood sugar for the first time |
|
c)
|
Verbally instructing the patient about how to obtain a finger-stick blood sugar |
|
d)
|
Offering a brochure that describes the technique for checking a blood sugar |
|
|
37.
|
It is a busy day on the medical-surgical floor, and the nurse must teach a patient ready for discharge about his medications. How can the nurse most efficiently utilize her time and provide this education?
|
a)
|
Write down instructions so the patient can read them at home. |
|
b)
|
Discuss the information while assisting the patient with his bath. |
|
c)
|
Educate the patient about his medications as each one is given. |
|
d)
|
Follow up with the patient after discharge with a phone call. |
|
|
38.
|
After sustaining injuries in a motor vehicle accident, a patient experiences a decrease in blood pressure and an increase in heart rate and respiratory rate despite surgical intervention and fluid resuscitation. Which stage of the general adaptation syndrome is the patient most likely experiencing?
|
a)
|
Alarm |
|
b)
|
Resistance |
|
c)
|
Exhaustion |
|
d)
|
Recovery |
|
|
39.
|
You are caring for a patient with numerous physiological complaints. A family member tells you that the patient is pretending to have the symptoms of a stomach ulcer to avoid going to work. Which somatoform disorder is this patient most likely experiencing?
|
a)
|
Hypochondriasis |
|
b)
|
Somatization |
|
c)
|
Somatoform pain disorder |
|
d)
|
Malingering |
|
|
40.
|
After a patient has an argument with her husband, she becomes verbally abusive to the nurse who is caring for her. Which coping mechanism is this patient exhibiting?
|
a)
|
Reaction formation |
|
b)
|
Displacement |
|
c)
|
Denial |
|
d)
|
Conversion |
|
|
41.
|
When counseling a patient about behaviors to reduce stress, which of the following goals should the nurse put on the care plan?
|
a)
|
“The patient will limit his intake of fat to no more than 15% of the daily calories consumed.” |
|
b)
|
“The patient will eat 3 meals per day at approximately the same time each day.” |
|
c)
|
“The patient will limit his intake of sugar and salt, as well as sweet and salty foods.” |
|
d)
|
“The patient will consume no more than 3 alcoholic beverages a day.” |
|
|
42.
|
Before entering the room of a patient who is angry and yelling, the nurse removes her stethoscope from around her neck. The best rationale for doing so is that the stethoscope:
|
a)
|
Could be used by the patient to hurt her. |
|
b)
|
Might cause the patient not to trust her. |
|
c)
|
Would distract her from focusing on the patient. |
|
d)
|
Will function as another stressor for the patient. |
|
|
43.
|
A patient is in crisis. After assessing the situation, what should the nurse do first?
|
a)
|
Determine the cause of the crisis. |
|
b)
|
Intervene to relieve the patient’s anxiety. |
|
c)
|
Decide on the type of help the patient needs. |
|
d)
|
Ensure the safety of both the nurse and patient. |
|
|
44.
|
Which polysaccharide is stored in the liver?
|
a)
|
Insulin |
|
b)
|
Ketones |
|
c)
|
Glycogen |
|
d)
|
Glucose |
|
|
45.
|
While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. She emphasizes that doing so greatly reduces the risk of which complication?
|
a)
|
Kidney failure |
|
b)
|
Liver failure |
|
c)
|
Stroke |
|
d)
|
Lung cancer |
|
|
46.
|
Patients may be deficient in which vitamin during the winter months?
|
|
47.
|
A patient is brought to the emergency department experiencing leg cramps. He is irritable, his temperature is elevated, and his mucous membranes are dry. Based on these findings, the patient most likely has excess levels of which mineral?
|
a)
|
Sodium |
|
b)
|
Potassium |
|
c)
|
Phosphorus |
|
d)
|
Magnesium |
|
|
48.
|
A patient who was prescribed furosemide (Lasix) is deficient in potassium. Which of the following is an appropriate goal for this patient? The patient will increase his consumption of:
|
a)
|
Bananas, peaches, molasses, and potatoes. |
|
b)
|
Eggs, baking soda, and baking powder. |
|
c)
|
Wheat bran, chocolate, eggs, and sardines. |
|
d)
|
Egg yolks, nuts, and sardines. |
|
|
49.
|
During the day shift, a patient’s temperature measures 97°F (36.1°C) orally. At 2000, the patient’s temperature measures 102°F (38.9°C). What effect does this rise in temperature have on the patient’s basal metabolic rate?
|
a)
|
Increases the rate by 7% |
|
b)
|
Decreases the rate by 14% |
|
c)
|
Increases the rate by 35% |
|
d)
|
Decreases the rate by 28% |
|
|
50.
|
After instructing a mother about nutrition for a preschool-age child, which statement by the mother would indicate correct understanding of the topic?
|
a)
|
“I usually use dessert only as a reward for eating other foods.” |
|
b)
|
“I will hide vegetables in casseroles and stews to get my child to eat them.” |
|
c)
|
“I do not give my child snacks; they simply spoil his appetite for meals.” |
|
d)
|
“I know that lifelong food habits are developed during this stage of life.” |
|
|
51.
|
The nurse is providing nutrition counseling for a patient planning pregnancy. The nurse should emphasize the importance of consuming which nutrient to prevent neural tube defects?
|
a)
|
Folic acid |
|
b)
|
Calcium |
|
c)
|
Protein |
|
d)
|
Vitamin D |
|
|
52.
|
A middle-aged patient with a history of alcohol abuse is admitted with acute pancreatitis. This patient will most likely be deficient in which nutrients?
|
a)
|
Iron |
|
b)
|
B vitamins |
|
c)
|
Calcium |
|
d)
|
Phosphorus |
|
|
53.
|
Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will:
|
a)
|
Limit his intake of protein. |
|
b)
|
Avoid foods containing gluten. |
|
c)
|
Restrict his use of sodium. |
|
d)
|
Limit his intake of potassium-rich foods. |
|
|
54.
|
Which portion of a nutritional assessment must the registered nurse complete?
|
a)
|
Analyzing the data |
|
b)
|
Obtaining intake and output |
|
c)
|
Weighing the patient |
|
d)
|
Obtaining the history |
|
|
55.
|
Which laboratory test result most accurately reflects a patient’s nutritional status?
|
a)
|
Albumin |
|
b)
|
Prealbumin |
|
c)
|
Transferrin |
|
d)
|
Hemoglobin |
|
|
56.
|
While performing a physical assessment, the student nurse tells her instructor that she cannot palpate her patient’s bladder. Which statement by the instructor is best? “You should:
|
a)
|
Try to palpate it again; it takes practice but you will locate it.” |
|
b)
|
Palpate the patient’s bladder only when it is distended by urine.” |
|
c)
|
Document this abnormal finding on the patient’s chart.” |
|
d)
|
Immediately notify the nurse assigned to your patient.” |
|
|
57.
|
The nurse is caring for a patient who underwent a bowel resection 2 hours ago. His urine output for the past 2 hours totals 50 mL. Which action should the nurse take?
|
a)
|
Do nothing; this is normal postoperative urine output. |
|
b)
|
Increase the infusion rate of the patient’s IV fluids. |
|
c)
|
Notify the provider about the patient’s oliguria. |
|
d)
|
Administer the patient’s routine diuretic dose early. |
|
|
58.
|
Which outcome is appropriate for the patient who underwent urinary diversion surgery and creation of an ileal conduit for invasive bladder cancer?
|
a)
|
Patient will resume his normal urination pattern by (target date). |
|
b)
|
Patient will perform urostomy self-care by (target date). |
|
c)
|
Patient will perform self-catheterization by (target date). |
|
d)
|
Patient’s urine will remain clear with sufficient volume. |
|
|
59.
|
The student nurse asks the provider if she will prescribe an indwelling urinary catheter for a hospitalized patient who is incontinent. The provider explains that catheters should be utilized only when absolutely necessary because:
|
a)
|
They are the leading cause of nosocomial infection. |
|
b)
|
They are too expensive for routine use. |
|
c)
|
They contain latex, increasing the risk for allergies. |
|
d)
|
Insertion is painful for most patients. |
|
|
60.
|
A patient who sustained a spinal cord injury will perform intermittent self-catheterization after discharge. After discharge teaching, which statement by the patient would indicate correct understanding of the procedure?
|
a)
|
“I will need to replace the catheter weekly.” |
|
b)
|
“I can use clean, rather than sterile, technique at home.” |
|
c)
|
“I will remember to inflate the catheter balloon after insertion.” |
|
d)
|
“I will dispose of the catheter after use and get a new one each time.” |
|
|
61.
|
A mother tells the nurse at an annual well child checkup that her 6-year-old son occasionally “wets himself”. Which response by the nurse is appropriate?
|
a)
|
Explain that occasional wetting is normal in children of this age |
|
b)
|
Tell the mother to restrict her child’s activities to avoid wetting |
|
c)
|
Suggest “time-out” to reinforce the importance of staying dry |
|
d)
|
Inform the mother that medication is commonly used to control wetting |
|
|
62.
|
Which task can the nurse safely delegate to the nursing assistive personnel?
|
a)
|
Palpating the bladder of a patient who is unable to void |
|
b)
|
Administering a continuous bladder irrigation |
|
c)
|
Providing indwelling urinary catheter care |
|
d)
|
Obtaining the patient’s history and physical assessment |
|
|
63.
|
A patient is prescribed furosemide (Lasix), a loop diuretic, for treatment of congestive heart failure. The patient is at risk for which electrolyte imbalance associated with use of this drug?
|
a)
|
Hypocalcemia |
|
b)
|
Hypokalemia |
|
c)
|
Hypomagnesemia |
|
d)
|
Hypophosphatemia |
|
|
64.
|
The nurse is teaching an older female patient how to manage urge incontinence at home. What is the first-line approach to reducing involuntary leakage of urine?
|
a)
|
Insertion of a pessary |
|
b)
|
Intermittent self-catheterization |
|
c)
|
Bladder training |
|
d)
|
Anticholinergic medication |
|
|
65.
|
What is the best technique for obtaining a sterile urine specimen from an indwelling urinary catheter?
|
a)
|
Use antiseptic wipes to cleanse the meatus prior to obtaining the sample. |
|
b)
|
Briefly disconnect the catheter from the drainage tube to obtain sample. |
|
c)
|
Withdraw urine through the port using a needleless access device. |
|
d)
|
Obtain the urine specimen directly from the collection bag. |
|
|
66.
|
Based on the stage of physical development at which toilet training becomes physically possible, for which age would a goal of “Achieves toilet training by the end of this month” be most appropriate?
|
a)
|
18 months |
|
b)
|
2 1/2 years |
|
c)
|
3 1/2 years |
|
d)
|
4 years |
|
|
67.
|
The nurse has taught a patient about the primary risk factors for irritable bowel syndrome. Which behavior by the patient would be evidence of learning? The patient:
|
a)
|
Reduces her intake of gluten-containing products. |
|
b)
|
Does not consume foods that contain lactose. |
|
c)
|
Consumes only 4 cups of caffeinated coffee per day. |
|
d)
|
Takes measures to reduce her stress level. |
|
|
68.
|
A patient is diagnosed with an intestinal infection after traveling abroad. The nurse should encourage the intake of which food to promote healing?
|
a)
|
Yogurt |
|
b)
|
Pasta |
|
c)
|
Oatmeal |
|
d)
|
Broccoli |
|
|
69.
|
A nurse is teaching wellness to a women’s group. The nurse should explain the importance of consuming at least how much fluid to promote healthy bowel function (assume these are 8-ounce glasses)?
|
a)
|
2 to 4 glasses a day |
|
b)
|
4 to 6 glasses a day |
|
c)
|
6 to 8 glasses a day |
|
d)
|
8 to 10 glasses a day |
|
|
70.
|
A patient with a skin infection is prescribed cephalexin (an antibiotic) 500 mg orally q 12 hours. The patient complains that the last time he took this medication, he had frequent episodes of loose stools. Which recommendation should the nurse make to the patient?
|
a)
|
Stop taking the drug immediately if diarrhea develops. |
|
b)
|
Take an antidiarrheal agent such as diphenoxylate. |
|
c)
|
Consume yogurt daily while taking the antibiotic. |
|
d)
|
Increase your intake of fiber until the diarrhea stops. |
|
|
71.
|
Which collaborative interventions will help prevent paralytic ileus in a patient who underwent right hemicolectomy for colon cancer?
|
a)
|
Administering morphine 4 mg intravenously every 2 hours for pain |
|
b)
|
Administering IV fluids at 125 ml/hr |
|
c)
|
Inserting an indwelling urinary catheter to monitor I&O |
|
d)
|
Keeping the patient NPO until bowel sounds return |
|
|
72.
|
The nurse is assessing a patient who underwent bowel resection 2 days ago. As she auscultates the patient’s abdomen, she notes low-pitched, infrequent bowel sounds. How should she document this finding?
|
a)
|
Hyperactive bowel sounds |
|
b)
|
Abdominal bruit sounds |
|
c)
|
Normal bowel sounds |
|
d)
|
Hypoactive bowel sounds |
|
|
73.
|
The healthcare team suspects that a patient has an intestinal infection. Which action should the nurse take to help confirm the diagnosis?
|
a)
|
Prepare the patient for an abdominal flat plate. |
|
b)
|
Collect a stool specimen that contains 20 to 30 ml of liquid stool. |
|
c)
|
Administer a laxative to prepare the patient for a colonoscopy. |
|
d)
|
Test the patient’s stool using a fecal occult test. |
|
|
74.
|
The nurse must irrigate the colostomy of a patient who is unable to move independently. How should the nurse position the patient for this procedure?
|
a)
|
Semi-Fowler’s position |
|
b)
|
Left side–lying position |
|
c)
|
Supine with the head of the bed lowered flat |
|
d)
|
Supine with the head of bed raised to 30 degrees |
|
|
75.
|
A mother of a school-age child seeks healthcare because her child has had diarrhea after being ill with a viral infection. The patient states that after vomiting for 24 hours, his appetite has returned. Which recommendation should the nurse make to this mother?
|
a)
|
Consume a diet consisting of bananas, white rice, applesauce, and toast. |
|
b)
|
Drink large quantities of water regularly to prevent dehydration. |
|
c)
|
Take loperamide [an antidiarrheal] as needed to control diarrhea. |
|
d)
|
Increase the consumption of raw fruits and vegetables. |
|
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
|
| |
1.
|
Which area(s) should the nurse inspect when assessing for cyanosis in a dark-skinned patient? Select all that apply.
|
| |
2.
|
Which factor(s) place(s) the patient at risk for constipation? Choose all that apply.
|
